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Why do stars like Adele keep losing their voice?

The long read: More and more singers are cancelling big shows and turning to surgery to fix their damaged vocal cords. But is the problem actually down to the way they sing?

I dont even know how to start this, Adele wrote in an online letter to fans on 30 June. The previous night, she had played the second show of a sold-out, four-night residency at Wembley Stadium. These dates, in front of audiences of 98,000, were supposed to be the triumphant conclusion of her record-setting, 123-date world tour. But on stage, something had just felt wrong.

Ive struggled vocally both nights, she wrote. I had to push a lot harder than I normally do. I felt like I constantly had to clear my throat. After the second show, Adele went to see her doctor, who told her she had damaged her vocal cords and had no option but to cancel her remaining shows. The most powerful young voice in the music business had fallen silent. To say Im heart broken would be a complete understatement, she wrote.

Though only 29, Adele had been here before. Six years earlier, she had suffered a haemorrhage to her vocal cords after singing live on a French radio program. In order to repair the injury, she underwent an incredibly delicate, high-risk medical intervention: vocal cord microsurgery. In this operation, the surgeon wields miniature scalpels and forceps attached to foot-long poles that are guided down the throat to excise whatever damaged tissue is robbing the vocal cords of their elasticity, and depriving the voice of its natural timbre, range and clarity.

Adeles surgeon, Dr Steven Zeitels, was after a nasty polyp that had formed under her epithelium, the thin outer layer of the vocal cord. Zeitels carefully snipped the layer with a scalpel, and then, with a forcep, pulled back the tissue like a flap, exposing the polyp below. With a second forcep he pulled out the gooey, infected mass, and zapped the remaining haemorrhaged surface with a laser to stop the bleeding and prevent scarring.

The margin for error in such surgeries is measured in fractions of a millimetre. You cant let the instruments touch any healthy tissue. Dig too deep, Zeitels knew, and he would risk damaging the superficial lamina propria, the soft, pliable underlayer of Adeles vocal cords. If he pierced that, he told me, there would be no way to preserve the power and suppleness of her voice.

On 12 February 2012, three months after her surgery, Adele swept up six awards at the Grammys, including album of the year and song of the year. In her acceptance speech for best pop solo performance, she thanked Zeitels for restoring her voice. To most observers, it was a cheering comeback story, but for a handful of medical specialists it was a watershed moment. For years, vocal cord microsurgery had been considered risky. (In 1997, an unsuccessful surgical procedure left Julie Andrews already damaged voice beyond repair.) More than the physical risk, though, singers feared the damage to their careers that could follow if word got out. In the world of showbusiness, it was safer to be seen as a singer with a healthy young voice than as a one-time great with surgically repaired cords.

Now, Adele had suddenly swept away the stigma. In the years since, Zeitels business has boomed, along with those of many of his peers. They have no shortage of patients: there is an epidemic of serious vocal cord injuries in the performing arts. In addition to his work on Adele, Zeitels, who directs the Massachusetts General Hospital Center for Laryngeal Surgery and Voice Rehabilitation, has repaired the cords of more than 700 performing artists, including Sam Smith, Lionel Richie, Bono and Cher. Michael Bubl, Keith Urban, Meghan Trainor and Celine Dion have also had to quit touring to get their cords surgically repaired. In a mark of how attitudes to surgery have changed, both Smith and Bubl broke the news of their surgeries to their fans via Instagram.

There is no precise data on the number of performers who have gone under the knife over the years. But several surgeons told me they estimate that vocal cord surgery has been performed on thousands of pop, rock and classical singers, as well as on theatre and stage musical stars. Cancelled shows reverberate across social media and hit a struggling music industry hard. When Adele pulled out of her remaining two Wembley shows this summer, nearly 200,000 tickets had to be refunded. Its unclear if she will ever tour again.

After Adeles 2011 surgery, Zeitels became something of a celebrity. Occasionally, a reporter asked him if Adele was cured for good. He made no assurances, but told Channel 4s Jon Snow that her surgically repaired voice sounds smoother now than before.

While the media was celebrating this miracle surgery, one woman in the music industry raised a dissenting voice. According to Lisa Paglin, a former opera singer turned voice coach, Zeitels had simply found a temporary fix; in the not too distant future, Adele would once again be forced off the stage and back into the operating theatre. It was a prediction that Paglin and Marianna Brilla, her coaching partner, were willing to stake their reputations on. The rash of vocal injuries silencing our most promising young talents, they argued, is too big a problem to be solved by microsurgery.

How many surgeries would Dr Zeitels consider performing on Adele? Or on anyone? After surgery, unless a singer makes major changes, return to performing means a return to the vocal abuse that put her/him on the operating table in the first place, Paglin wrote, in the small trade publication Intermezzo. Concerts injury surgery rest concerts injury surgery. Is this the life of a professional singer?

When Adele cancelled the final nights of her recent tour, Brilla and Paglin felt saddened but vindicated. For more than a decade, they have been pushing for a revolution in the way that almost every modern performer has been taught to use their voice. After years of painstaking research in musical archives, early scientific journals and the classroom, Brilla and Paglin say they can deliver what medical science has failed to: a permanent fix for vocal burnout.

Their solution requires the revival of an all-but-vanished singing method that is not just beautiful to the ear, but also easy on the throat. Some of their ageing and beleaguered clients described it to me as a kind of fountain of youth. But their cure is not without controversy. It is based on a provocative theory that has been gaining ground among a small cadre of international talents: that we have all been singing completely wrong even Adele.

Singing is a rough business. Every vocal performance involves hundreds of thousands of micro-collisions in the throat. The vocal cords also known as vocal folds are a pair of thin, reed-like, muscular strips located inside the larynx, or voice box, in the throat. They are shaped like a wishbone, and contain the densest concentration of nerve tissue in the body.

When we are silent, the cords remain apart to facilitate breathing. When we sing or speak, air is pushed up from the lungs, and the edges of the cords come together in a rapid chopping motion. The air causes the cords to vibrate, creating sound. The greater the vibration, the higher the pitch. By the time a soprano hits those lush high notes, her vocal cords are thwacking together 1,000 times per second, transforming a burst of air from her lungs into music powerful enough to shatter glass.

Beautiful singing requires lithe cords, but all that slapping together can wear down their fine, spongy surface and lead to tiny contusions. Over years of heavy use, nodules, polyps or cysts form on the vocal folds, distorting the sound they create. For a singer, the first sign of trouble is often the wobble. His pitch fluctuates on and off key because his ragged cords have lost their natural vibrato their ability to resonate properly. Then theres the hole, a point on the scale where a singers vibrating vocal cords fail to produce the proper tone. Try as he might, those notes will exit his mouth flat or, worse, as a barely audible gasp.

Brilla and Paglin have been saying this for years. You cannot solve the problem by simply relieving the symptom, Brilla said. Its a motor problem. The singer has to understand its the way youre running your engine the techniques theyre using to sing. If you dont fix the engine, its going to happen again.

Teatro La Nuova Fenice, a 19th-century opera house built in the neoclassical style, sits at the top of the small hill town of Osimo in central Italy, just inland of the Adriatic Sea. In the grand lobby of the building is a marble plaque commemorating the night in 1927 when the Italian tenor Beniamino Gigli, one of the greatest talents of his era, performed here. Gigli packed concert halls across Europe and the Americas in a career that spanned five decades.

Gigli is an icon of the purer, more natural singing style that characterised a period when vocal injuries were almost unheard of, say Brilla and Paglin. They have a small teaching studio in a cul-de-sac below La Nuova Fenice. Brilla, a dramatic soprano with a fearless air, first became obsessed with the fragility of the human voice more than 50 years ago, as a teenage opera singer growing up in Pennsylvania coal country. A doctor there diagnosed her with a problem common among young singers with big voices: her vocal cords werent coming together properly. She had a hole. Over the next few decades, she cycled through nearly 30 teachers, including legends such as Antonio Tonini and Ellen Faull, trying to learn to sing in a style like Giglis at once powerful, clear and sustainable over the course of many years.

Brilla met Paglin, a lyric soprano who appears small next to Brilla, while studying voice at Indiana Universitys school of music. The two bonded over their love for Italian opera and their frustration with the way singing was taught, even by their legendary teacher Margaret Harshaw. Feeling that the giants of music instruction didnt have the key to vocal longevity, Brilla and Paglin determined that they would be the ones to unlock the secret.

In 1977, Brilla won a prestigious Fulbright scholarship to travel to Italy to search for a way to sing beautifully without risking injury. There, she heard glimpses of perfect arias from older, mostly Italian opera singers who learned their craft in the early 20th century. These singers seemed to effortlessly produce clear, powerful musical tones, and so many of them were still performing with vigour well into their 60s, 70s and 80s. To Brilla, they held a clue to the vocal longevity lost to singers today.

Paglin soon joined her in Rome, where they started spending hours each day at the national sound archive, La Discoteca di Stato, listening to early recordings. They also scoured libraries for texts that discussed how operatic and classical singing techniques had changed over the centuries. When they werent researching, they were performing; big talents in their own right, they performed in many of the major opera houses and music halls of Italy and Austria. This put them in the presence of more masters, whom they peppered with questions. They also tracked down other ageing opera stars, teachers and conductors.

Their research pointed Brilla and Paglin to a surprising conclusion: that responsibility for the modern decline of the voice lay at the feet of Verdi, Wagner and Puccini. These three composers were the pop music sensations of their day. Music scholars credit them with being the first to challenge their singers to push their voices to new limits, in order to capture the emotional ups and downs their characters were feeling. Think of the teenage Japanese bride in Puccinis Madama Butterfly, her heart breaking, desperately watching the seas for a sign her love will return, or the thunderous battle cries of the Valkyries in Wagners Ring cycle. If youre going to kill off the main character of your show, you need genuine rage and pathos on stage.

But Brilla and Paglin heard something different that the emotionally charged, full-throated, operatic singing style Verdi and Wagner made popular in the late 19th century and that Puccini amped up even further in the early 20th century had subsequently infiltrated all singing genres and public performances. With each passing decade, the style grew more extreme. To illustrate the point, when I visited the duo earlier this summer, Paglin pulled from their sprawling research library a file containing a series of images. The first was a photograph, taken in 1920, of the legendary Italian tenor Enrico Caruso mid-aria. Caruso seems to be enjoying himself, even as the camera flashes; its as if hes talking to a friend, not baying at the audience. This is natural singing, Paglin said.

As she flipped from image to image, we travelled towards the present, a decade at a time. The photographs of the more contemporary singers including the tenor Rolando Villazn, who has suffered multiple vocal injuries looked like horror-movie stills: their mouths were wide open, eyes bulging, neck veins popping, as if they were screaming. There was none of Carusos easy calm.

Caruso and Gigli produced legendarily big sounds, but with an effort that todays performers might deride as somewhat wimpy. Compare Carusos 1916 recording of O Sole Mio with Villazns 2010 rendition. Carusos is powerful, but not so powerful that the lyrics crash into one another and become indecipherable; and even at the height of the aria, he doesnt drown out the strings. That Brilla and Paglin had identified this contrast wasnt enough. They wanted to reverse-engineer exactly how Caruso and his contemporaries sang.